A lung cancer diagnosis can have a devastating impact on patients, particularly as it relates to psychological well-being.
Rates of depression and anxiety among lung cancer patients vary. According to Barbara Andersen, MD, of Ohio State University, the literature indicates a prevalence of around 20% of depressive disorders and 10% of anxiety disorders in these patients.
In a new study she and her colleagues published in , they found that more than one-third of patients with newly diagnosed advanced stage non-small cell lung cancer have moderate to severe symptoms of depression and many with depression have comorbid anxiety.
In this study, 186 patients completed a telephone survey measuring psychological and physical symptoms, stress, and day-to-day functioning. Results showed that 8% of the patients had severe depressive symptoms, while 28% had moderate depressive symptoms.
In addition, patients with severe depressive symptoms reported:
- High levels of hopelessness, with one-third of patients with severe depression reporting thoughts of suicide
- Anxiety symptoms consistent with generalized anxiety disorder
- High levels of traumatic, cancer-specific stress
- A view of lung cancer as very consequential for their lives, and not controllable with treatment
- Severe symptoms and pain, along with substantial functional impairment
"These are the kinds of patients for whom depression is unlikely to improve simply with the passage of time," Andersen told 鶹ý. "And if they improve, it takes months for their symptoms to resolve. They are people who need further evaluation and direction towards treatment to address their symptoms."
And there is further urgency to the question of treating depression, considering its potential impact on survival.
"The literature is clear in showing depression to be s significant predictor of survival," Andersen said. "Further, there is a general toxicity of depressive symptoms for individuals with illness, and even more so in patients with cancer. We are dealing with something that is known to impact survival, so if patients are identified and treated for depression, they will do better."
Screening for distress in cancer patients is recommended in several national guidelines. For example, the (co-authored by Andersen) in 2014 recommending that "all patients with cancer and cancer survivors be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care."
The guidelines call for healthcare practitioners to identify resources in their institution and across their community for the treatment of depressive and anxiety symptoms, noting that the availability and accessibility of supportive care services will be important for helping patients such as these.
The document also warned that it is common for patients with depression or anxiety to not follow through on referrals or comply with treatment recommendations, and that practitioners should assess compliance with individual or group psychological/psychosocial referrals, as well as patient satisfaction with those services.
"Screening is more or less being implemented," noted Andersen. "but beyond screening the question is now that you've screened the patient, what are you going to do with the people who have screened positive? That is where facilities are struggling in terms of having the resources, or having investigated places, or ways, to refer patients, or having the resources there in their facility so that patients can be further evaluated and treated. More generally, I think medicine is struggling with that."
In their study in Lung Cancer, Andersen and her co-authors wrote that providing patients with referrals and follow-up mental healthcare is critically important, particularly considering the improved survival benefits that are achievable with targeted therapies and immunotherapies.
"Without appropriate referral and care, patients' understanding of their disease will be suboptimal, decision-making and engagement in treatment will be impaired, tolerance of symptoms and treatment side effects will be lowered, and motivation and efforts to maintain functional status will decline," the team warned.
Carolyn Presley, MD, MHS, a geriatric oncologist specializing in thoracic cancers at Ohio State University, and who participated in Andersen's study, said she thinks that many times oncologists are better at monitoring physical symptoms than they are at monitoring mental health or mood symptoms, "which a lot of times actually manifest as physical symptoms."
"Fatigue, diarrhea, or an upset stomach -- these could all be physical manifestations of anxiety and depression," Presley told 鶹ý. "As healthcare providers, we could do a better job of linking physical and mental health symptoms. And then once we diagnose depression or anxiety, as providers and a society, we have a really long way to go in figuring out how to treat them in a way that is not overly burdensome to the patient."
In that sense, Presley explained, referring patients to outside psychiatrists or psychologists may not be the best way to treat patients who not only show symptoms of anxiety and depression, but also have to deal with the burden of cancer treatment.
Presley is currently working on an intervention called , the goal of which is to assess the feasibility of a weekly supervised virtual health-assisted physical therapy plus relaxation intervention delivered to older adults with advanced thoracic malignancy.
"If you are going to do physical therapy or see a psychologist you will have to go in person once or twice a week," said Presley. "Patients with lung cancer are just trying to make it to the doctor and get their cancer treatment. The idea behind this program is that when they are in clinic and seeing their oncologist for their treatment, they will also see physical therapy and a psychologist, but in off weeks they will also do physical therapy and relaxation visits virtually, decreasing the burden on both the patient and the caregiver."
"We know [a lung cancer patient's] treatment will be pretty intense, and they have received a pretty heavy diagnosis," she continued. "This intervention has been specifically developed to improve their physical activity and their mood in the hope it will preserve or improve their functional status and resiliency while they go through lung cancer treatment. It is really trying to alleviate the treatment burden on patients, which can exacerbate things like anxiety and depression."
Disclosures
Andersen received funding from The Ohio State University Comprehensive Cancer Center Pelotonia.
Presley received funding from the National Cancer Institute through The Ohio State University K12 Training Grant for Clinical Faculty Investigators (K12CA133250).